Patient Safety

1
Patient Safety Dr Foster Ethics Committee
Meeting 16/7/08
2
Where are we nationally?

• There were around 12 million admissions to NHS
  acute trusts in 2006/07
• Estimates suggest that one in ten patients in
  hospital experiences an incident which puts their
  safety at risk, and that about half of these
  could have been prevented

3
What these figures might mean to you locally

• Potentially an average of 7,300 patients per year
  per hospital suffer an adverse event
• Double decker bus seats 73 people
• 100 bus loads of patients per year per hospital
• Nearly 2 bus loads per week per hospital

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5
REGULATED
HAZARDOUS
ULTRA-SAFE
(gt1/1000)
(lt1/100K)
100,000
Health Care
Driving
10,000
1,000
Scheduled
Airlines
Total lives lost per year
100
Chemical
European
Mountain
Manufacturing
Railroads
Climbing
10
Bungee
Chartered
Nuclear
Jumping
Power
Flights
1
1
10
100
1,000
10,000
100,000
1million
10million
Number of encounters for each fatality
6
It could never happen here?
7
LD History
Leading the NHS in Patient Safety
Patients Safety Strategy Developed and approved
Building Momentum
England Pilot Site for Health Foundation Safer
Patients Initiative
IHI Pursuing Perfection IMPACT Programme MA
Community of Practice
Hospital Standardised Mortality Rate 111
Adverse Drug Events Internal Collaborative
2001
2002
2003
2004
2005
2006
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The Ambition
To No needless deaths No needless harm No
Helplessness No delays No waste No inequity

• From
• Avoidable deaths
• Adverse incidents
• Patients no control
• Patients waiting
• Duplication, re-work
• Variation in access

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Key Goals

• Reduce Hospital Standardised Mortality Rate
  (HSMR) to below 80
• Deliver the aims of the Safer Patients
  Initiative
• Reduce adverse events by 50 and create a culture
  that puts patients at the centre of everything we
  do

Stretch targets
10
Safer Patient Initiaitve - workstreams

• Leadership
• Critical Care
• Ward
• Medication
• Peri operative 29 simultaneous initiatives 35
  additional measuresPlus
• No Avoidable Infection Strategy
• No Avoidable Pressure Sores Strategy

11
The SPI Leadership work stream

• Leadership walk around
• Cultural survey
• New leadership programme

12
Leadership

• "Chief Executives need to know their hospital
  standardised mortality rates.
• As accountable officers, we should be deeply
  concerned about the avoidable deaths.
• There should be nothing more important to a CEO
  than saving lives and demonstrating to their
  staff they are interested in this."
• Stephen Ramsden

13

• Leading Patient Safety
• Making patient safety our no. 1 priority being
  explicit
• Board commitment
• Managerial/clinical partnership
• Sharing learning and inspiring ambition
  throughout the NHS - eg. seeking the lowest HSMR
  in the UK
• Continuous improvement culture that integrates
  patient safety, patients experience and
  efficiency

14
Gaining Clinical Commitment

• Case Note Review Findings
• Avoidable deaths
• Incomplete DNR policies
• Poor record keeping communication
• Incomplete observations Failure to rescue
• Lack of response to results
• Adverse drug events
• Lack of standardisation, e.g thromboprophylaxis
• Links with C Difficile and MRSA

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Building the infrastructure for delivery

• The resource question
• Leadership development building capability
• Improvement expertise
• Empowering and freeing up front line staff
• Measuring improvement

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No avoidable pressure sores and infections
Monthly rates H.A. Pressure Ulcers sore incidence
Monthly Rates C.difficile
17
Weekly Cardiac Arrests Outside A/E Department
Special Cause Flag
B
A
15
10
Individual Value
5
0
-5
1st Apr
7th Jan
5th Feb
4th Feb
17th Oct
30th Apr
15th Oct
2nd May
12th Dec
3rd April
24th July
14th Nov
20th Aug
10th Dec
29th May
18th Sept
7th March
27th June
5th March
25th June
4th Jan 08
10th Nov 07
22nd August
27th may 07
22nd July 07
25th April 08
16th Sept 07
2nd March 08
11th Jan 2004
Period
18
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Perioperative workstream
Compliance with maintaining patients temp within
normal range perioperatively
Compliance with DVT prophylaxis according to
protocol
20
Overall impact
Adverse events 70 reduction
HMSR From 11 worse to 10 better
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Final Message

• Quality assurance, clinical governance, risk
  management, learning from incidents, regulation
  are essential but inadequate.
• In addition
• A transformational, ambitious, proactive, local
  programme using improvement science, patient
  stories and rigorous measurement to move heart
  and minds, will help achieve a culture of patient
  safety.
• And
• This is a CEO/Leadership priority.